The Enigma of Plantar “Fasciitis” (Fasciosis) and How to Treat It

©2025 T. Agnew-craiyon.com

Years ago, when I worked with the dancers at Pittsburgh Ballet Theatre, I often treated foot-related dysfunctions. In their brief careers, ballet dancers torture their bodies, often straining their feet and ankles under the pressure of graceful performance.

The relentless repetition of en pointe (standing on toes), constricting footwear, and extreme positions of spiral-based movement place intense stress on the lower limbs (shoulders suffer as well).

Yet, one injury was more prevalent than others, and it’s a common issue with everyday people, too.

Plantar fasciitis (actually fasciosis, PF) is a painful and often chronic condition involving the fascia — the band of tissue that runs from the base of the toes to the calcaneus (heel). It’s a painful disorder that sometimes makes weight bearing on feet almost impossible.

In my sports medicine career, I treated athletes, artists (who spend hours on their feet) and dancers with PF, but I found it most common with weekend hikers and people who didn’t exercise at all.

What remains germane to every case is the incredible frustration in dealing with it — partly because of misunderstanding what causes it and why it seems to linger.

Dissecting Plantar “Fasciitis”

I spent many years doing human dissection with a focus on the body’s fascia system (I’ve written about fascia here), and it’s what enlightened me about this tissue, the largest sensory organ in our bodies (see our textbook for a wonderful resource on anatomy).

Like the fascia layers from the back of the head to the toes, and the top of the toes to the sides of the skull, the plantar aponeurosis on the bottom of our feet transforms the deep fascia into a strong, protective layer that spans the sole of the foot. However, this distinct tissue connects in a line to the occipital bone (back of the head). I’ll explain why this is important later.

I felt this band of tissue during my dissections labs, and it’s composed of a matrix of fibers that, when held up to a light, resemble alien spider webs. We attempted to tear it between two forceps, but it would not budge. It’s that strong. It’s built like steel.

This dense band of connective tissue anchors, supports, and shields the foot’s vital internal structures (like the visceral fascia that encapsulates our organs) during movement and weight-bearing activities.

It thickens at the center, forming the robust aponeurosis, while the tissue tapers along the sides. Structurally, the fascia divides into three distinct sections — medial, lateral, and central — each contributing to the stability and function of the foot’s arch.

It’s important to distinguish that oxygen consumption of tendons and ligaments is seven times lower than that of skeletal muscles — this makes healing slow and difficult because of lack of sufficient blood flow.

Tendinopathy, Explained

To understand PF, it’s necessary to examine what happens to the plantar band to cause PF, and what makes it a stubborn injury to heal.

The name “plantar fasciitis” is misleading, and it irked me when I practiced— “itis” refers to inflammation, as in tendonitis.

Researchers once believed the fascia becomes inflamed, but studies now show that it degenerates and develops micro tears. Tendinosis, or more inclusively tendinopathy, describes this process in tendons and is now the more appropriate definition for most pseudo-tendonitis cases. For PF, Plantar fasciosis is the proper name.

In my years in practice, I never saw one patient with inflammation in the fascia — almost all the cases I saw were chronic, longstanding PF with damaged collagen matrix in the fascia.

Causes of PF

Shoes with toe spring and narrow, tapered toe boxes force your big toe into an unnaturally extended and inward position.

This posture causes the abductor hallucis — the muscle that moves your big toe away from your foot’s centerline — to tug on the flexor retinaculum. This can also cause bunions, painful bumps that form on the joint of the large toe. This is another common dysfunction people face — especially women who wear high heels — and I’ll write about this soon.

It’s important to distinguish that oxygen consumption of tendons and ligaments is seven times lower than that of skeletal muscles — this makes healing slow and difficult because of lack of sufficient blood flow.

That tension can compress the posterior tibial artery, the main vessel delivering blood to the sole of your foot. As blood flow slows, the tissues in your foot’s arch begin to deteriorate as walking and other forces pull on it, setting the stage for chronic pain and degeneration.

Other causes are most often soft tissue-related — tight gastrocnemius (calf), toe flexors (especially the tightness between toes), and overuse. With professional athletes, excessive corticosteroid injections cause the plantar matrix to break down. While one or two injections are usually benign, more than this does more harm than good.

Solving PF

My former patients went through the same “system” of diagnosis, were all recommended the same protocols, and most of these patients had no relief. Or, if they did, the pain recurred in one-three months. It is a common gaffe in the medical machine — exceptional amounts of out-of-pocket costs on orthotics, casts, and MRIs.

An orthopedic physician usually orders physical therapy, but they sometimes use:

· Cortisone injections

· Night splints (just no — bracing the foot is not a solution. Movement is.)

· Taping

· Orthopedic Inserts

There is very little evidence that these traditional treatments protocols have any real benefit, especially in the long term. So, what works?

The secret to solving PF is common sense and specific manual therapy. Since plantar fasciosis involves torn and disrupted fascia matrix, the goal is to help restore the alignment of this tissue through releasing muscle tissue and strengthening.

Patients who underwent manual therapy reported less pain after four weeks and noticeable functional gains at both four weeks and six months. By the six-month mark, those who combined manual therapy with exercise described their symptoms as improved. In contrast, patients who followed traditional therapy rated their improvement as only moderate.

Here is my protocol:

Active Gastrocnemius Stretching and Strengthening

The calf muscle is a powerful lower leg muscle that attaches into the calcaneus. While it does not attach to the plantar fascia, it has a strong biomechanical connection.

If this muscle is tight, which it usually is in those with PF, it changes foot strike and creates tension in the plantar fascia. You must release it daily, especially before weight-bearing activity (see my active stretching video here for tips).

To actively stretch this muscle, you can use a strap or rope to pull the foot into dorsiflexion (foot moves toward the knee) from a seated position. Use the muscles to do the work, then apply a gentle stretch. When done correctly, you’re actually pumping the foot in short repetitions.

Another way is to use a step or piece of wood. Move the feet off the step until only the toes are at the edge. Drop the heal to the floor, repeat.

To strengthen this muscle, you can do toes raises on the stair, lifting your body weight up on your toes. If you strengthen the calf, you must also strengthen the opposite muscle, the tibialis. You can do this by standing against a wall and pulling your toes up so you are on your heels.

Stretching the Plantar Fascia

This is the most important exercise to do daily. While the plantar fascia does not stretch like a muscle, we want to create a gentle tension in it as it pulls from the toes to the calcaneus (heal). This helps “pump” blood and nutrients into the fascia and helps realign the fascia matrix.

As I said earlier, the plantar fascia connects to the line that runs from toes to the skull. As you stretch the calf and perform the movement below, tuck the chin to your chest as you do it. Crazy as it sounds, this creates tension on the body’s posterior fascial line.

Cross the leg over the other with the foot resting as in the picture. Actively dorsiflex your foot and pull your toes into extreme extension as you flex your foot. Like the calf stretch, this is a pumping motion, repeated 2–3 sets of 10 repetitions.

Between sets, apply pressure into the fascia with your thumbs, moving it from the heal to the toes. Press deeply (it will not be comfortable).

Creating Space in the Toes

Tight-fitting shoes and heels often compress the toes and shorten the webbing between them. Clasp the first two toes and move them away from each other by stretching the webbing. Repeat for every toe, performing 2–3 sets of 10 repetitions.

Cryotherapy

Lastly, apply daily ice to the bottom of the foot, but do not use an ice pack. Instead, freeze a bottle of water and place it on the floor. Position your foot over the bottle and roll it from the toes to the heal, applying as much pressure as you can stand (yes, it will hurt).

Do this 2–3 times per day, increasing the pressure with each round.

Other Treatment Options

Cold laser therapy is a proven adjunct for PF. I used two smart cold lasers in my practice with outstanding results. You can purchase consumer-grade devices that, while not as powerful as medical-grade devices, work just fine for home use (stay away from “hot” lasers. If they can burn a hole through a table, you do not need it on your skin!)

Deep tissue massage over the calf and plantar fascia helps immensely. Foam shoe inserts? Not so much. This is a Band-Aid. The goal is to condition the soft tissues so they can do what they are supposed to do without extra cushion: provide a steel-like band designed to withstand extreme movements.

Mexican-born runners always run barefoot and never have PF issues. Why? They have conditioned their feet. Consider switching to minimal shoes as it does help strengthen the fascia.

Summary

PF is a chronic condition that can make walking or weight bearing painful and often impossible. It’s still misunderstood and labeled as an itis, when the actual cause is fasciosis.

Because the plantar fascia has a limited blood supply, healing takes longer. The secret to solving PF is addressing the micro tears in the tissue and applying the correct exercises to help it realign.

Active stretching of lower leg and toe muscles, “stretching” the plantar fascia, and cryotherapy is imperative to help this tissue heal.

Avoiding tight-fitting shoes and stretching the calf before weight bearing is vital. Keep in mind that excessive weight places more pressure on the fascia, so those that are overweight face more of a challenge.

You can manage PF by applying common sense and maintaining stretching and strengthening — just have patience, it could take weeks to heal.